GIP receptor agonism blocks chemotherapy-induced nausea and vomiting.

OBJECTIVE: Nausea and vomiting remain life-threatening obstacles to successful treatment of chronic diseases, despite a cadre of available antiemetic medications. Our inability to effectively control chemotherapy-induced nausea and vomiting (CINV) highlights the need to anatomically, molecularly, and functionally characterize novel neural substrates that block CINV. METHODS: Behavioral pharmacology assays of nausea and emesis in 3 different mammalian species were combined with histological and unbiased transcriptomic analyses to investigate the beneficial effects of glucose-dependent insulinotropic polypeptide receptor (GIPR) agonism on CINV. RESULTS: Single-nuclei transcriptomics and histological approaches in rats revealed a topographical, molecularly distinct, GABA-ergic neuronal population in the dorsal vagal complex (DVC) that is modulated by chemotherapy but rescued by GIPR agonism. Activation of DVCGIPR neurons substantially decreased behaviors indicative of malaise in cisplatin-treated rats. Strikingly, GIPR agonism blocks cisplatin-induced emesis in both ferrets and shrews. CONCLUSION: Our multispecies study defines a peptidergic system that represents a novel therapeutic target for the management of CINV, and potentially other drivers of nausea/emesis.

Screening study of anti-emetics to improve GDF15-induced malaise and anorexia: Implications for emesis control.

Considerable preclinical and clinical attention has focused on the food intake and body weight suppressive effects of growth differentiation factor 15 (GDF15) and its elevated blood levels as a consequence of disease states and disease treatment therapeutics. We have previously reported that exogenous administration of GDF15 induces anorexia through nausea and emesis in multiple species. Importantly, GDF15 signaling as a meditator of chemotherapy-induced anorexia and emesis has recently been demonstrated in both murine and nonhuman primate models. The mechanism, however, by which GDF15 induces malaise and the utility of existing therapeutic targets to counteract its effects remain largely unknown. Using a dose of GDF15 that mimics stimulated levels following chemotherapy administration and reliably induces malaise, we sought to screen anti-emetics that represent distinct pharmacotherapeutic classes hypothesized to reduce GDF15-induced effects in rats. Strikingly, our results showed that none of the tested compounds were effective at preventing GDF15-induced malaise. These results illustrate the complexity of GDF15 signaling mechanism and may have important implications for medical conditions characterized by elevated GDF15 levels and incomplete symptom control, such as chemotherapy-induced nausea and vomiting.

Peripherally restricted oxytocin is sufficient to reduce food intake and motivation, while CNS entry is required for locomotor and taste avoidance effects.

OBJECTIVES: Oxytocin (OT) has a well-established role in reproductive behaviours; however, it recently emerged as an important regulator of energy homeostasis. In addition to central nervous system (CNS), OT is found in the plasma and OT receptors (OT-R) are found in peripheral tissues relevant to energy balance regulation. Here, we aim to determine whether peripheral OT-R activation is sufficient to alter energy intake and expenditure. METHODS AND RESULTS: We first show that systemic OT potently reduced food intake and food-motivated behaviour for a high-fat reward in male and female rats. As it is plausible that peripherally, intraperitoneally (IP) injected OT crosses the blood-brain barrier (BBB) to produce some of the metabolic effects within the CNS, we screened, with a novel fluorescently labelled-OT (fAF546-OT, Roxy), for the presence of IP-injected Roxy in CNS tissue relevant to feeding control and compared such with BBB-impermeable fluorescent OT-B12 (fCy5-OT-B12; BRoxy). While Roxy did penetrate the CNS, BRoxy did not. To evaluate the behavioural and thermoregulatory impact of exclusive activation of peripheral OT-R, we generated a novel BBB-impermeable OT (OT-B12 ), with equipotent binding at OT-R in vitro. In vivo, IP-injected OT and OT-B12 were equipotent at food intake suppression in rats of both sexes, suggesting that peripheral OT acts on peripheral OT-R to reduce feeding behaviour. Importantly, OT induced a potent conditioned taste avoidance, indistinguishable from that induced by LiCl, when applied peripherally. Remarkably, and in contrast to OT, OT-B12 did not induce any conditioned taste avoidance. Limiting the CNS entry of OT also resulted in a dose-dependent reduction of emesis in male shrews. While both OT and OT-B12 proved to have similar effects on body temperature, only OT resulted in home-cage locomotor depression. CONCLUSIONS: Together our data indicate that limiting systemic OT CNS penetrance preserves the anorexic effects of the peptide and reduces the clinically undesired side effects of OT: emesis, taste avoidance and locomotor depression. Thus, therapeutic targeting of peripheral OT-R may be a viable strategy to achieve appetite suppression with better patient outcomes.

Implementation of the integrated palliative care outcome scale in acute care settings - a feasibility study.

OBJECTIVE: Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings. METHOD: A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals.ResultFactors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers' involvement in the implementation differed between the units.Significance of the resultsThe feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.

Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care.

Unresolved grief and its consequences. A nationwide follow-up of teenage loss of a parent to cancer 6-9 years earlier.

PURPOSE: The early loss of a parent is a tragedy and a serious life event. This study investigated grief resolution and morbidity in cancer-bereaved teenagers 6 to 9 years after the loss of a parent to cancer. METHODS: In a nationwide population-based study of 622 of 851 (73 %) youths who as teenagers 6 to 9 years earlier had lost a parent to cancer, we explored the magnitude of unresolved grief and its association with psychological and physiological morbidity. Participants answered a study-specific anonymous questionnaire including questions about if they had worked through their grief and about their current health. RESULTS: Six to nine years post-loss 49 % reported unresolved grief (8 % no and 41 % a little grief resolution). They had, in comparison with youths reporting resolved grief, statistically significantly elevated risks, e.g. for insomnia (sons' relative risk (RR) 2.3, 95 % CI 1.3-4.0; daughters' RR 1.7, 95 % CI 1.1-2.7), fatigue (sons' RR 1.8, 95 % CI 1.3-2.5; daughters' RR 1.4, 95 % CI 1.1-1.7) and moderate to severe depression, i.e. score >9, PHQ-9 (sons' RR 3.6, 95 % CI 1.4-8.8; daughters' RR 1.8, 95 % CI 1.1-3.1). Associations remained for insomnia in sons, exhaustion in daughters and fatigue in both sons and daughters when depression, negative intrusive thoughts and avoiding reminders of the parents' disease or death were included in a model. CONCLUSIONS: Approximately half of cancer-bereaved youth report no or little grief resolution 6 to 9 years post-loss, which is associated with fatigue, sleeping problems and depressive symptoms.

Physiological, morphological, and immunochemical parameters used for the characterization of clinical and environmental isolates of Acanthamoeba.

The factors that characterize Acanthamoeba strains as harmless or potentially pathogenic have not been elucidated. Analysing the in vitro and in vivo parameters of Acanthamoeba samples, including heat tolerance at temperatures close to that of the human body, cytopathic effects, and their ability to cause infections in animals, has been proposed to identify their pathogenic potential. Another promising criterion for differentiating strains is the analysis of their biochemical and immunochemical properties. In this study, a comparative evaluation between clinical and environmental Acanthamoeba isolates was performed on the basis of physiological, morphological, and immunochemical criteria. Crude antigens were used to characterize the protein profiles by electrophoresis and immunize mice to produce polyclonal and monoclonal antibodies. The antibodies were characterized using ELISA, Western blotting, and immunofluorescence techniques. The results obtained with polyclonal antibodies suggest the presence of specific proteins for each studied isolate and co-reactive immunochemical profiles among conserved components. Ten monoclonal antibody clones were obtained; mAb3 recognized 3 out of 4 samples studied. The results of this study may help standardize criteria for identifying and characterizing Acanthamoeba strains. Taken together, our results support the view that a set of features may help differentiate Acanthamoeba species and isolates.

Variation in medication use in cancer patients at the end of life: a cross-sectional analysis.

PURPOSE: Despite advances in cancer treatment, patients still die with unnecessary suffering. Therefore, high-quality end-of-life care is needed. Variations in medication use at the end of life may suggest areas for improvement. This study aims to describe the use of medications during the last days of life of cancer patients and to explore the possibility of using it as a quality measure. METHODS: We conducted an international survey on experts' opinions regarding potentially inappropriate medications for dying patients. Subsequently, a chart review of deceased cancer patients was conducted, which assessed the current medication use in different settings. RESULTS: The mean number of medications used in the last 3 days of life was 4.8 (SD 2.1). Hospital patients were less likely than hospice patients to receive opioids, midazolam, haloperidol, and drugs for pulmonary secretions or nausea/vomiting. Over 90 % of experts rated 12 medications as unlikely to be appropriate. Hospital patients were more likely than hospice patients to receive these potentially inappropriate medications. Before the implementation of an end-of-life care pathway, hospital patients had a higher probability, than after, to receive potentially inappropriate medication. Moreover, after implementation of such pathway, patients for whom a pathway was not used were more likely to receive potentially inappropriate medications than patients for whom it was used. CONCLUSION: Medication use at the end of life varies widely by setting, both for potentially appropriate and inappropriate medications. Combining experts' opinion and current medication use resulted in the identification of 16 medications that might be used to assess the quality of cancer care at the end of life.

Testing the indicative value of magnetic susceptibility measurements for concluding on site potentials and risks provoked by fly ash deposition.

The article presents results of testing the indicative value of magnetic susceptibility for fly ash deposition and its effects on forest site properties. Base saturation and concentrations of Ca and Mg were used as indicators for nutrient pools resulting from fly ash deposition. Concentrations of Fe, Al, Mn, Cd and Black Carbon were used as indicators for risks of leaching. The correlation of magnetic susceptibility with concentrations of nutrient, acidic cations, heavy metals, base saturation and Black Carbon was calculated. Additionally, we tested the suitability of magnetic susceptibility as a parameter in a linear regression based model to predict the concentrations of Ca, Mg, Fe, Al, Mn, Cd and Black Carbon. We were able to show a positive correlation between magnetic susceptibility and the selected indicators. In contrast to previous studies, we were also able to demonstrate the suitability of magnetic susceptibility to predict the size of fly ash deposition influenced nutrient pools mainly for humus layers, especially for Oa horizons. The spatial distribution of magnetic susceptibility showed also a positive correlation with regionalized base saturation. However, because of the data base and other factors impacting the measurement and modeling results, some shortcomings of using a linear regression model must be noted. From these results, we concluded that magnetic susceptibility might be a valuable parameter in a multiple regression based approach, but should not be used alone for predicting effects of fly ash deposition.

GIS-based probability assessment of natural hazards in forested landscapes of Central and South-Eastern Europe.

We assessed the probability of three major natural hazards--windthrow, drought, and forest fire--for Central and South-Eastern European forests which are major threats for the provision of forest goods and ecosystem services. In addition, we analyzed spatial distribution and implications for a future oriented management of forested landscapes. For estimating the probability of windthrow, we used rooting depth and average wind speed. Probabilities of drought and fire were calculated from climatic and total water balance during growing season. As an approximation to climate change scenarios, we used a simplified approach with a general increase of pET by 20%. Monitoring data from the pan-European forests crown condition program and observed burnt areas and hot spots from the European Forest Fire Information System were used to test the plausibility of probability maps. Regions with high probabilities of natural hazard are identified and management strategies to minimize probability of natural hazards are discussed. We suggest future research should focus on (i) estimating probabilities using process based models (including sensitivity analysis), (ii) defining probability in terms of economic loss, (iii) including biotic hazards, (iv) using more detailed data sets on natural hazards, forest inventories and climate change scenarios, and (v) developing a framework of adaptive risk management.

How to support forest management in a world of change: results of some regional studies.

This article presents results of several studies in Middle, Eastern and Southeastern Europe on needs and application areas, desirable attributes and marketing potentials of forest management support tools. By comparing present and future application areas, a trend from sectoral planning towards landscape planning and integration of multiple stakeholder needs is emerging. In terms of conflicts, where management support tools might provide benefit, no clear tendencies were found, neither on local nor on regional level. In contrast, on national and European levels, support of the implementation of laws, directives, and regulations was found to be of highest importance. Following the user-requirements analysis, electronic tools supporting communication are preferred against paper-based instruments. The users identified most important attributes of optimized management support tools: (i) a broad accessibility for all users at any time should be guaranteed, (ii) the possibility to integrate iteratively experiences from case studies and from regional experts into the knowledge base (learning system) should be given, and (iii) a self-explanatory user interface is demanded, which is also suitable for users rather inexperienced with electronic tools. However, a market potential analysis revealed that the willingness to pay for management tools is very limited, although the participants specified realistic ranges of maximal amounts of money, which would be invested if the products were suitable and payment inevitable. To bridge the discrepancy between unwillingness to pay and the need to use management support tools, optimized financing or cooperation models between practice and science must be found.

Health care-related predictors of husbands' preparedness for the death of a wife to cancer--a population-based follow-up.

BACKGROUND: If we can learn how to increase preparedness before the death of a loved one, we can possibly decrease the next-of-kin's long-term morbidity. METHODS: In a population-based study, 691 of 907 (76%) men in Sweden who lost a wife to cancer 4-5 years earlier answered an anonymous questionnaire about their preparedness at the time of their wife's death as well as potential predictors for preparedness. RESULTS: A final logistic regression model indicates following predictors for preparedness, among others: the length of the widower's intellectual awareness time before his wife's death [relative risk (RR) 4.1, confidence interval (CI) 2.7-6.1], the widower could take in the information that his wife's disease could not be cured (RR 3.5, CI 2.3-5.2), the couple had arranged their economical affairs (RR 1.5, CI 1.3-1.7), the wife had stayed at a palliative care unit during her last months of life (RR 1.2, CI 1.1-1.4) and health care personnel supported the husband to participate in his wife's care (RR 1.6, CI 1.3-2.1). CONCLUSIONS: We identified several care-related factors that may influence the preparedness of men before their wife's death to cancer. These factors can be considered in future intervention studies aiming at influencing preparedness before the death of a loved one.

Palliative day care--a study of well-being and health-related quality of life.

AIM: The aim of the study was to study the outcomes of palliative day care, in terms of health-related quality of life and the emotional well-being of cancer patients participating in a palliative day care programme for a period of five weeks, compared with a group of palliative cancer patients not participating in day-care. METHODS: The day care sample comprised of patients in a palliative day care programme delivered in two different day care facilities. Participants in the comparison group were recruited from a palliative home care service facility. All patients had a cancer diagnosis. The participants were invited to respond to two questionnaires once a week for a period of five weeks; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30) and the Mood Adjective List (MACL). RESULTS: The participants in the day care group and the comparison group reported similar levels of perceived functioning and symptoms, as measured by the EORTC QLQ-30, with no significant differences between the groups. However, the day care group reported higher levels of emotional well-being as measured by the MACL than the comparison group reported, although these differences were not statistically significant.

The existential impact of starting corticosteroid treatment as symptom control in advanced metastatic cancer.

Treatment with corticosteroids often results in increased appetite, reduced nausea and improved well-being in patients with advanced metastatic cancer. Therefore, we have studied the existential impact of starting corticosteroid treatment as symptom control in this patient group using qualitative content analysis with both a descriptive and an interpretative focus. Ten patients were interviewed before and after 1 week of treatment with 4 mg betamethasone. Prior to treatment, patients reported distressing symptoms, deterioration and diminished autonomy, symbolising threat and death. Corticosteroid treatment produced symptom relief in the majority of the patients. They reported enhanced physical abilities and experienced feelings of a more normalized life and strengthened autonomy, symbolising health and hope. This transfer from threat to hope has important existential consequences in end-of-life care and should be addressed when communicating goals of treatment and care with the patient and family.

Fatigue dimensions in patients with advanced cancer in relation to time of survival and quality of life.

To understand the relation between fatigue and patients emotional situation at the end of life, this cross-sectional study aimed to explore the association between multidimensional aspects of fatigue, emotional functioning and quality of life (QoL) in patients with advanced cancer at the end of life. Patients with advanced cancer answered fatigue related measurements (Borg Category Ratio-10 scale, Multidimensional Fatigue Inventory-20, Swedish Occupational Fatigue Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30), when admitted for specialised palliative care. A total of 228 patients with a median length of survival of 63 days were included. In relation to time of survival, fatigue increased closer to death, in both global and multidimensional aspects, as well as the patient's experience of being sleepy. Marital status was found to affect the experience of fatigue in both global and multidimensional ratings of fatigue. The association between the experience of fatigue and feelings of being tense, worried, irritable or depressed and rated QoL decreased and was not evident closer to death. Fatigue in all dimensions increased, as patients got closer to death. The association between fatigue and both QoL and negative emotions faded away during the last days and weeks of life.

Quality of life in terminal care--with special reference to age, gender and marital status.

OBJECTIVES: This study was conducted to explore symptoms, other quality of life (QoL) aspects and impact of age, gender, marital status, cancer diagnosis and time of survival in patients with advanced cancer admitted to palliative care. PATIENTS AND METHODS: A cross-sectional study of 278 cancer patients completing the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 at referral to palliative care. MAIN RESULTS: Gynaecological and gastro-intestinal tract cancers were the most common. Mean age was 67 years; 62% were female. Median survival was 43 days and 39% lived less than 30 days. Patients reported impaired general QoL and high occurrence of symptoms (44 and 100% for diarrhoea and fatigue, respectively). Fatigue, appetite loss and dyspnoea were reported as most severe (mean values of 80, 59 and 51, respectively, 0-100 scales). Married/cohabiting patients and younger patients reported lower functional abilities and more symptoms. No impact of diagnoses on QoL parameters was found. Patients closest to death did not differ significantly from those with longer time to live in social functioning. CONCLUSION: Young and married patients may be at higher risk for perceived low quality of life at the end of life. EORTC QLQ-C30 could be used as a clinical tool for screening of symptoms and reduced functioning in palliative care, but may not be appropriate for use in the most severely ill patients. Limitations of the instrument and the need for robust measurements of patient mix are discussed. Proxy ratings of physical symptoms and nurse responsibility to include QoL assessment in daily practice would increase attrition and decrease selection bias.

The unrecognised cost of cancer patients' unrelieved symptoms:a nationwide follow-up of their surviving partners.

We investigated if a cancer patient's unrelieved symptoms during the last 3 months of life increase the risk of long-term psychological morbidity of the surviving partner. All women (n=506) living in Sweden under 80 years of age, who lost their husband/partner owing to cancer of the prostate in 1996 or of the urinary bladder in 1995 or 1996 were asked to answer an anonymous postal questionnaire, 2-4 years after their loss. The widows' psychological morbidity was associated with the patient's unrelieved mental symptoms. When the patient was perceived to have been very anxious during last three months of life (compared to no observed symptoms) the relative risks for the widows' psychological morbidity were: 2.5 (1.4-4.3) for depression and 3.4 (1.4-8.2) for anxiety. When comparing reports of the patient's pain (much vs no), the relative risks were 0.8 (0.5-1.2) for widowhood depression, and 0.8 (0.4-1.7) for widowhood anxiety. The patients were found to have had adequate access to physical pain control but poor access to psychological symptom control. Efficiency in diagnosing and treating psychological complications of terminally ill cancer patients may not only improve their quality of life but possibly also prevent long-term psychological morbidity of their surviving partners.

Biological aspects of a Brazilian strain of Entamoeba dispar.

A strain of Entamoeba dispar was characterized by clinical diagnosis, serological and electrophoretical isoenzyme analysis and by the polymorphism of a 482 bp genomic fragment analysis. The pathogenesis and virulence of this strain was investigated considering the experimental infection in hamster livers in association with the original intestinal microbiota. Liver lesions were observed in hamsters experimentally infected with trophozoites from xenic cultures, but not from the monoxenic cultures. Moreover, clones obtained from re-isolated strain Wil1R1 showed a distinct biological behavior. In fact, animals inoculated with Wil1R1ClB3 showed an intense acute inflammatory reaction with destructive focal hepatic lesions. These lesions were characterized as amebic abscesses. The association between bacteria and ameba has been fairly well studied because it affects the pathogenicity of the amebas and has important therapeutic implications. In this study, we demonstrated that E. dispar in association with the original microbiota is able to produce lesions in hamster liver in spite of its having been considered to be non-pathogenic in the hamster model. Based on these results we suggest that diagnosis of amebiasis needs to be made with more care and that clinical and therapeutical procedures need to be revised.

Comparative toxicity of acrylic acid to marine and freshwater microalgae and the significance for environmental effects assessments.

In this study, we compared the sensitivity of freshwater and marine organisms to two structurally similar substances, acrylic acid and methacrylic acid. Reported acute toxicity data (L(E)C50-values) for freshwater organisms range from 0.1 to 222 mg/l and 85 to >130 mg/l for acrylic acid and methacrylic acid, respectively. The large variation in toxicity data for acrylic acid is due to a specific toxicity to certain species of freshwater microalgae, with algae EC50-values being two to three orders of magnitude lower than L(E)C50-values reported for fish and invertebrates. To evaluate the sensitivity of marine organisms, ecotoxicity data was generated for ten species of microalgae, one invertebrate species and one fish species. For methacrylic acid, we found a marine acute toxicity that ranged from 110 to >1260 mg/l, which is comparable to reported data on freshwater organisms. In strong contrast, the resulting L(E)C50-values for acrylic acid ranged from 50 to >1000 mg/l, and there was no specific sensitivity of marine algae when compared to marine invertebrates and fish. For acrylic acid, therefore, use of the available freshwater toxicity data for an effects assessment for the marine environment is likely to overestimate the hazard and risk from this substance. Overall, the results of the study suggest that ecotoxicity data generated on freshwater species may not always be appropriate for the effects assessments of organic chemicals in the marine environment, thus emphasising the importance of using ecologically relevant data to assess environmental risk.

Dimensions of fatigue during radiotherapy. An application of the Multidimensional Fatigue Inventory.

The aim of the present study was to describe fatigue in a group of irradiated cancer patients. Fatigue was assessed prospectively in 81 Swedish cancer patients, using the Multidimensional Fatigue Inventory (MFI-20), which was also validated in the study, the Karolinska Sleepiness Scale and a Borg CR10 scale before curative radiotherapy, at the end of therapy and 1 and 3 months after treatment. The mean age of these patients was 56 years; 90% were female; and 65% were being treated for cancer of the breast. The absorbed radiation dose was 50 Gy or lower in 90% of the patients. A clear peak in experienced fatigue according to the three scales was seen at the end of treatment. In the MFI-20 the dimensions of General fatigue, Physical fatigue and Reduced activity, were more pronounced than the aspects of Mental fatigue and Reduced motivation. Comparison with other studies using the same instrument in other irradiated patients revealed a similar pattern. The internal consistency of the Swedish version of the MFI-20 was good. The MFI-20 is shown to be a valid instrument for assessing fatigue in patients undergoing radiotherapy.